Boerhaave’s Syndrome• "Spontaneous" esophageal

rupture was described by Boerhaave in 1724.– Dutch admiral Baron John von

Wassenauer overindulged on roast duck and wine, subsequently vomited/died

– Autopsy revealed gastric contents in pleural space

– at the time surgery was considered “a fools venture”

Herman Boerhaave1668-1738

• Dutch physician, botanist, chemist, medical educator, philosopher– self taught medicine– attended dissections but not lectures– married daughter of a rich merchant– did lectures for $– treated rich and famous– insisted on autopsies– bedside teaching– did consults by mail– Never had a bad hair day

Boerhaave’s Syndrome• Classic triad

– vomiting, – excruciating chest pain– subcutaneous emphysema

CXR

• Left pleural effusion/ left hydropneumothorax in 12 to 24 hours.

• Pulmonary infiltrates• SubQ air• Widened mediastinum

Boerhaave’s Syndrome• Anatomy

– perf of esophagus -> mediastinum– negative pressure promotes soilage– 90% tears along the left, posterolateral wall of

the distal esophagus– role of esoph. disease is ?

• Etiology– retching against a closed glottis

• also laughing, childbirth, sz, trauma, heavy lifting• most common cause upper endoscopy (~60%)

Causes

• Endoscopy (~60%)• Dilations• NG tubes• Neck/abd Surgery• Post emetic• Infection

• Blunt trauma• Caustics• Foreign body• Esoph disease

Boerhaave’s Syndrome Clinical features -may be delayed!

• Pain, (pleuritic, back, chest, abd)

• Dyspnea• Subq Air/

mediastinal air• Hamman’s

crunch (systolic)

• Vomiting• Dysphagia • Change in voice• Sepsis

Boerhaave’s Syndrome

• Treatment– ABCs– NPO– Antibiotics/fluids– Consultation

• Outcome– survival 65-90%– poor survival w/ delayed dx >48hrs

Boerhaave’s Syndrome• Diagnosis

– often difficult– 1/3 presentations are atypical– Differential dx

• Spont. Mediastinum• Thoracic Aortic Aneurysm• PE• PUD• Pancreatitis• Mesentaric ischemia

Follow up

• Pt underwent thoracotomy, repair• Episode of lidocaine toxicity in the

ICU• Discharged home